lung transplantation

1. JAMIA MILIA ISLAMIA
CENTRE FOR PHYSIOTHERAPY & REHABILITATION SCIENCES
PRESENTATION OF PHYSIOTHERAPY IN CARDIOPULMONARY
CONDITIONS(BPT-402)
TOPIC- LUNG TRANSPLANTATION
SUBMITTED TO- DR. JAMAL ALI MOIZ
SUBMITTED BY- TANVEER BHOLA
BPT 4TH YEAR
PRESENTATION DATE-29.12.2020
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2. • Lung transplantation refers to the surgical procedure of removal of one or
both lungs from a patient of an end stage lung disease and the
replacement of lung with healthy organs from a donor.
• Donor lungs can be retrieved from a living donor or deceased donor
(RTA or brain dead).
HISTORICAL PERSPECTIVE-
• In 1963, James Hardy performed the first human lung transplantation in a
58 year old patient with bronchogenic carcinoma, Although the patient
survived for only 18 days.
• Successive attempts at different centers were made over the next 20
years, but there was no long-term survival of patients.
• In 1983, Cooper at the University of Toronto performed the first long-
term successful single-lung transplantation on a patient with end-stage
pulmonary fibrosis.
• Three years later, Cooper and colleagues performed the first successful
double-lung transplant on a patient with end-stage emphysema.
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3. INDICATIONS-
• Obstructive lung disease
Chronic obstructive pulmonary disease (COPD)
• Restrictive lung disease
Idiopathic pulmonary fibrosis (IPF)
Interstitial lung disease (ILD)
• Infectious lung disease
cystic fibrosis
Bronchiectasis
• pulmonary vascular disease
Primary pulmonary hypertension
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4. INDICATIONS IN SPECIFIC DISEASE CONDITIONS-
• Chronic obstructive pulmonary disease-
• BODE index of 7–10 or at least one of the following:
• History of hospitalization for exacerbation associated with acute
hypercapnia (PCO2 exceeding 50 mm Hg).
• Pulmonary hypertension or Cor Pulmonale, or both, despite oxygen
therapy.
• FEV1<20% and either DLCO<20% or homogenous distribution of
emphysema.
Table 1- the BODE index
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5. • Idiopathic pulmonary fibrosis-
• Histologic or radiographic evidence of UIP and any of the following:
• DLCO < 40% predicted.
• A 10% or greater decrement in FVC during 6 months of follow-up
• A decrease in pulse oximetry below 88% during a 6MWT or <250m
on 6MWT.
• Cystic fibrosis-
• FEV1 below 30 % predicted, or rapidly declining lung function
FEV1
• Increasing oxygen requirements
• Hypercapnia.
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6. CONTRAINDICATIONS-
• Absolute contraindications-
recent malignancy
active infection with hepatitis B or C virus associated with histologic
evidence of significant liver damage and HIV infection
active or recent cigarette smoking, drug abuse, or alcohol abuse
Significant chest wall/spinal deformity
severe psychiatric illness with noncompliance with medical care
absence of a consistent and reliable social support network
Untreatable advanced dysfunction of another major organ system
(heart, liver, kidney).
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7. • Relative contraindications-
Advanced age is associated with higher mortality rates, most centres
have an age cut-off; 50 years for heat-lung transplantation, 60 years
for bilateral lung transplantation & 65 years for single lung
transplantation.
Both obesity (BMI>30) and underweight nutritional status increase
the risk of post-transplant mortality.
Patients who are dependent on a ventilator prior to transplant have
higher mortality rates.
Severe or symptomatic osteoporosis.
The risk posed by other medical comorbidities, such as diabetes
mellitus, systemic hypertension, gastroesophageal reflux, and
coronary artery disease, must be assessed individually based on
severity of disease, presence of end-organ damage.
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8. RECIPIENT SELECTION-
• These procedures are offered to those patients with end-stage lung
disease who have the best opportunity for long term survival with
capacity for full rehabilitation
• Patients must have end stage pulmonary or cardiopulmonary disease
leading to severe impairment of quality of life with life expectancy of
less than 2 years.
• Patients although terminally ill, should be otherwise fit & free of other
disease.
• Stability & a firm commitment to idea of transplantation & a willingness
to comply the rigorous & often invasive medical management are the
prerequisites.
• All patients undergo a thorough assessment of cardiopulmonary status
including PFT, quantitative ventilation & perfusion scans, exercise
tolerance & supplemental oxygen requirements.
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9. DONOR SELECTION-
• Despite the shortage of donor lungs, only lungs from suitable perfused
organ donors are accepted for transplantation as status of the implanted
lung is one of the important predictors of outcome.
• The majority of donors are victims of gunshot wounds (31%),
intracranial haemorrhage (24%), and motor vehicle accidents (21%).
Only 5-10% of perfused organ donors have lungs acceptable for
transplantation.
• STANDARD LUNG DONOR CRITERIA;
Age < 55 years
Clear chest radiograph
PaO2 > 300 mm Hg on FIO2 1.0, PEEP 5 cm H2O
No history of Cigarette smoking
Absence of significant chest trauma
No evidence of aspiration or sepsis
No prior thoracic surgery on side of harvest
Absence of organisms on sputum Gram stain
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10. Absence of purulent secretions and gastric contents at bronchoscopy
Negative for HIV antibody, hepatitis B surface antigen, and hepatitis
C antibody
No active or recent history of malignancy
No chronic lung disease
• In matching a donor with a prospective recipient, the guidelines include
compatibility of ABO blood group, Size matching is done by comparing
the predicted lung volumes (total lung capacity and forced vital capacity)
of the potential donor and recipient calculated by established formulas
based on height, age and sex.
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11. SURGICAL TECHNIQUE-
• Single lung transplantation;
 Indications for single-lung transplantation
include chronic obstructive pulmonary
disease, pulmonary fibrosis, and primary
pulmonary hypertension.
 SLT is infrequently used in retransplant
operations on patients who have undergone
heart-lung transplantation previously &
developed bronchiolitis.
 A standard posterolateral thoracotomy is
performed through 5th intercostal space.
 The main pulmonary artery is encircled &
temporarily clamped, if the hemodynamic
stability & gas exchange are maintained the
procedure is continued with cardiopulmonary
bypass.
 The recipient lung is removed, leaving in
adequate length of pulmonary artery & veins.
 The bronchus is divided just above the origin
of upper lobe and donor bronchus is trimmed
two rings proximal to origin of upper lobe &
an end-to-end bronchial anastomosis is
created. 11
Figure 1- lung transplantation technique

12. • Double lung transplantation;
 More accurately known as bilateral sequential lung transplantation.
 Double-lung transplantation is indicated for patients with an infective process (e.g.,
cystic fibrosis, bronchiectasis) and also has been performed for chronic obstructive
pulmonary disease, pulmonary fibrosis, and primary pulmonary hypertension.
 Patient is placed in supine position & chest is opened through a clamp-shell incision
extending from one mid axillary line to the other.
 Bypass is frequently used for bilateral sequential lung transplantation.
 The presence of adhesions can complicates the operative procedure by increasing
length of operation & amount of blood loss.
 The recipient lungs are removed & donor lungs are implanted sequentially using same
technique as SLT.
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Figure 2- approaches to bilateral lung transplantation

13. POST-OPERATIVE CARE-
• Immediately following surgery, patient is placed in an ICU for
monitoring, normally for a period of few days.
• The patient is put on a ventilator to assist breathing
• Nutritional needs are generally met via nasogastric tube.
• Chest tubes are put in so that excess fluids are removed
• Because the patient is confined to bed, a urinary catheter is used.
• IV lines are used in the neck & arm for monitoring & giving medications.
Special care is taken to look for rejection of organ or infection.
• After few days, without any complications, the patient may be
transferred to general inpatient ward for further recovery. He average
stay in hospital following a lung transplant is generally one to three
weeks.
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14. PRE-OPERATIVE PHYSIOTHERAPY-
• This should began as soon as possible after the patient is admitted.
• The main aims are;
Gain the patient’s confidence/patient education
Clear lung fields
Teach respiratory control & inspiratory holding
Teach posture awareness
Teach mobility about the bed.
Teach arm, trunk & leg exercises.
• The education component covers the risks and benefits of surgery,
topics related to care in the post-op period, risks and benefits of
immunosuppressive agents and planning for the required follow up.
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15. • Clearing lung Fields-
 The patient must be discouraged from smoking.
Shaking, clapping and vibrations with postural drainage if necessary
must be used to clear the secretions from the sound lung.
 Huffing is taught as this is used in preference to coughing
postoperatively.
 The patient is instructed on how to support the wound during
coughing and huffing. The arm of unaffected side is placed across
the front of the thorax and around the affected side just below the
incision side giving firm pressure with the forearm and hand.
• Teaching the respiratory control-
Inspiratory exercises are taught for the sound lung together with the
inspiratory holding. This means that the patient is asked to take a
deep breath in, hold, then breathe in a little further, hold, then
breathe out.
 Breathing control has to be practiced after secretions have been
cleared.
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16. POST-OPERATIVE PHYSIOTHERAPY-
• Rehabilitation begun in first 24-48 hours after surgery is focused on
optimizing lung expansion and secretion clearance as well as on
breathing pattern efficiency, upper & lower extremity range of motion,
strength, basic transfers & gait stabilization activities.
• The aims of physiotherapy are to;
Clear secretions
Retain the full expansion of lungs
Prevent circulatory complications
Regain arm and spinal movements
Maintain good posture
Restore exercise tolerance
• Clearance of pulmonary secretions should be initiated on the first
postoperative day, provided the patient is stable, and may be needed three
or four times each day initially. Postural drainage with shaking or
vibration may be better tolerated than percussion due to incisional and
chest tube discomfort.
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17. • In the early stages, the following is a guide to a progressive exercise
regime:
 Day 1-2 : sitting out in a chair
 Day 2: upper limb exercises, static pedals
 Day 2-3: walk around bed in room
 Day 4: walk outside room
 Day 5 post operation to discharge : exercise bike, practices going
up and down stairs with breathing control.
• Outpatient Pulmonary Rehabilitation;
• After discharge from the hospital, patients are often expected to
continue pulmonary rehabilitation.
• An exercise program consisting of four to five 30-minute sessions of
continuous exercise weekly should be well tolerated in this phase of
rehabilitation.
• During outpatient therapy, exercise tolerance should be re-evaluated
periodically and the exercise prescription modified. A 6 minute walk
test may be performed just after discharge from the hospital.
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18. COMPLICATIONS-
• The most common problems in the acute postoperative period are
infection and acute cellular rejection. Of these complications, infection
has been identified as the greater cause of early death (within 6 months
of transplantation).
• Other complications are directly related to lung transplant surgery. Adult
respiratory distress syndrome/diffuse alveolar damage is an ischemic-
reperfusion injury related to poor graft preservation
• Immunosuppressive medications also can lead to complications. The
nephrotoxic effect of cyclosporine is well documented and can cause
both acute and chronic renal insufficiency.
• The second leading cause of late mortality in lung transplant recipients is
Bronchiolitis Obliterans, an inflammatory obstructive lung disease that
appears to result from chronic rejection. It creates a combined obstructive
and restrictive defect, the small airways becoming obstructed by
inflammation and then obliterated by granulation tissue, which then
fibroses. It occurs in 10-50% of recipients at around 6- 18 months after
surgery and has a mortality of 30-50%.
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19. REFERENCES-
• Downs, A. M. (1996). Physical therapy in lung transplantation. Physical
therapy, 76(6), 626-642.
• Singh, H., & Bossard, R. F. (1997). Perioperative anaesthetic
considerations for patients undergoing lung transplantation. Canadian
journal of anaesthesia, 44(3), 284-299.
• Physiotherapy in Respiratory Care-An evidence-based approach to
respiratory and cardiac management, Third edition, Alexandra Hough.
• Concise Clinical Review Lung Transplantation ,Robert M. Kotloff and
Gabriel Thabut.
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